Many Pediatricians Performing Circumcisions: Survey Tells Who Is Making the Cuts

Washington – Thirty-five percent of pediatricians in the United States are routinely performing circumcisions, compared with 60% of family physicians and 70% of obstetricians, a national survey found.

When the survey was presented here at the annual meeting of the Pediatric Academic Societies, the investigators expressed surprise at the number of pediatricians whoa re routinely circumcising infants.

Our impression is that lately more pediatricians are performing circumcisions, although because our survey was the first to look at [circumcision practice patterns], we cannot be sure, said pediatrician Howard J. Stang.

Dr. Stang and Dr. Leonard W. Snellman, of HealthPartners Health Maintenance Organization in White Bear Lake, Minn., analyzed 1,778 returned questionnaires sent to a nationally representative cohort of 3,500 pediatricians, family physicians, and obstetricians at the beginning of this year.

Considering that the American Academy of Pediatrics is reconvening its Task Force on Circumcision this summer to reformulate its 1989 neutral policy statement on the procedure, Dr. Stang thinks the survey could not have come at a better time.

In pediatrics and family medicine, the survey results point to a generation gap between circumcisers and those who don't do the procedure.

The highest percentage of pediatricians and family physicians who perform the minor surgery have been in practice for less than 10 years. However, obstetricians of all ages perform the procedure with only a small difference between those who have been in practice for 20 years versus those who are just out of residency.

Although pediatricians are still the smallest contingent of specializes who perform circumcisions, Dr. Stang believes that the perceived increase in interest in circumcision among young pediatricians could harken a new era of circumcision pain control.

We did not expect to find so may pediatricians performing circumcisions, but we did expect that those who did would be using anesthesia, Dr. Stang said in an interview. Strikingly, it is pediatricians who are most likely to administer some form of anesthesia to infants when we circumcise.

Of the 35% of pediatricians who circumcise, 71% us anesthetics, while only 56% of family physician circumcisers and 25% of obstetrician circumcisers use anesthetic.

The most commonly used anesthetic/analgesic agents were dorsal penile block with lidocaine (83%), oral sucrose (16%), acetaminophen (16%), and EMLA cream (9%).

A study presented a the meeting (see story below) found that dorsal penile nerve block provided better circumcision pain control than EMLA cream. According to Dr. Stang's survey, 86% of pediatricians who use an anesthetic during circumcision routinely use dorsal penile nerve block.

Anesthesia was most likely to be used by a recently trained pediatrician practicing in the western United States, Dr. Stang said during the poster presentation at the meeting. It was least likely to be used by an obstetrician in the Northeast.

The most often cited (54%) reason physicians in the survey offered for not giving anesthetic was concern about adverse effects. The second most popular reason (44%) was that they didn't think circumcision warranted anesthesia of any kind.

In an ironic twist, the survey found that female pediatricians and family physicians are more likely to administer anesthetics to circumcision patients than their male counterparts.

This was surprising, quipped Dr. Stang. We expected male physicians to have a keen appreciation for penile discomfort.

Graphic

Who's Doing Circumcisions.

West
Peds 52%
FPs 71%
OBs 54%

Midwest
Peds 33%
FPs 72%
OBs 72%

Northeast
Peds 13%
FPs 28%
OBs 84%

South
Peds 36%
FPs 57%
OBs 73%

Any Anesthetic Better Than None for Baby's Pain

EMLA Not As Effective as Nerve Block

Washington – A dorsal penile nerve block is more effective than the off-label use of EMLA cream to prevent pain in premature infants undergoing circumcision, Dr. Ronnie Guillet reported at the annual meeting of the Pediatric Academic Societies.

In a prospective, randomized, controlled and blinded study of 44 premature newborns, those who had a dorsal penile nerve block (DPNB) displayed less signs of obvious pain and had a minimal increase in heart rate during the procedure, compared with infants anesthetized with EMLA cream.

Dr. Guillet and her colleagues at Strong Children's Research Center at the University of Rochester (N.Y.) found that the 21 infants who received topical EMLA (2.5% lidocaine, 2.5% prilocaine) 1 hour before circumcision cried more, had more strained facial expressions, and were more fussy and restless during the procedure than those who underwent DPNB.

A control group of 20 infants were circumcised with out any anesthesia; all had maximal scores for observable pain and discomfort.

We endorse the use of anesthesia for neonatal circumcision, Megan Butler-O'Hara, R.N., a coauthor of the study said in the poster presentation at the meeting. DPNB is certainly better than EMLA, but EMLA may be better than no anesthetic at all.

Although some physicians have concluded that DPNB has too may potential risks, our studies and others have found it simple, safe, and the more effective method, she said during the presentation.

In 1989 member of the American Academy of Pediatrics' Task Force on Circumcision agreed that DPNB helps to reduce circumcision-related pain and distress but did not believe there were enough safety data to recommend routine utilization of the procedure.

The task force is convening to reconsider its circumcision policies this summer.

The investigators observed three cases of erythema (14%) in the EMLA cream group and 10 cases of hematoma (43.5%) at 24 hours post circumcision in the DPNB group. They considered both side effects minor.

Hematoma is a known side effect of DPNB, Ms. Butler-O'Hara said. But I would not consider it a major adverse effect.

DPNB consists of two subcutaneous injections of 1% lidocaine at the 10 o'clock and 2 o'clock positions at the base of the penis. The needle should be inserted only about 3-5 mm, and the lidocaine should be injected as the needle is withdrawn. Waiting 3 minutes should be sufficient to anesthetize the shaft of the penis.

A group of Canadian investigators has studied anesthesizing [sic] with a stronger formulation of EMLA cream (5% lidocaine, 5% prilocaine).

They found that it safely reduced the pain of circumcision in term infants in a controlled study (N. Engl. J. Med. 336:1197-1201, 1997).

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